Practice Test Maternity-nsg 100 Items

1 Maternity-Nsg Practice Test Part 1

c.

Relaxation of the pelvic joints

1.

When assessing the adequacy of sperm for

d.

Excessive weight gain

conception to occur, which of the following is the

7.

Which of the following represents the average

most useful criterion?

amount of weight gained during pregnancy?

a.

Sperm count

a.

12 to 22 lb

b.

Sperm motility

b.

15 to 25 lb

c.

Sperm maturity

c.

24 to 30 lb

d.

Semen volume

d.

25 to 40 lb

2.

A couple who wants to conceive but has been

8.

When talking with a pregnant client who is

unsuccessful during the last 2 years has undergone

experiencing aching swollen, leg veins, the

manydiagnostic procedures. When discussing the

nurse would explain that this is most probably the

situation with the nurse, one partner states, “We

result of which of the following?

know several friends in our age group and all of them

a.

Thrombophlebitis

have their own child already, Why can’t we have

b.

Pregnancy-induced hypertension

one?”. Which of the following would be the most

c.

Pressure on blood vessels from the enlarging uterus

pertinent nursing diagnosis for this couple?

d.

The force of gravity pulling down on the uterus

a.

Fear related to the unknown

9.

Cervical softening and uterine souffle are classified

b.

Pain related to numerous procedures.

c.

Ineffective family coping related to infertility.

a.

Diagnostic signs

d.

Self-esteem disturbance related to infertility.

b.

Presumptive signs

3.

Which of the following urinary symptoms does the

c.

Probable signs

pregnant woman most frequently experience during

d.

Positive signs

the first trimester?

10. Which of the following would the nurse identify as a

as which of the following?

presumptive sign of pregnancy?

a.

Dysuria

b.

Frequency

a.

Hegar sign

c.

Incontinence

b.

Nausea and vomiting

d.

Burning

c.

Skin pigmentation changes

4.

Heartburn and flatulence, common in the second

d. Positive serum pregnancy test 11. Which of the following common emotional reactions

trimester, are most likely the result of which of the following?

to pregnancy would the nurse expect to occur during

a.

Increased plasma HCG levels

the first trimester?

b.

Decreased intestinal motility

a.

Introversion, egocentrism, narcissism

c.

Decreased gastric acidity

b.

Awkwardness, clumsiness, and unattractiveness

d.

Elevated estrogen levels

c.

Anxiety, passivity, extroversion

5.

On which of the following areas would the

d.

Ambivalence, fear, fantasies

nurse expect to observe chloasma?

12. During which of the following would the focus of

a.

Breast, areola, and nipples

classes be mainly on physiologic changes, fetal

b.

Chest, neck, arms, and legs

development, sexuality, during pregnancy, and

c.

Abdomen, breast, and thighs

nutrition?

d.

Cheeks, forehead, and nose

a.

Prepregnant period

6.

A pregnant client states that she “waddles” when she

First trimester

walks. The nurse’s explanation is based on which of

b. c.

the following as the cause?

d.

Third trimester

a.

The large size of the newborn

13. Which of the following would be disadvantage of

b.

Pressure on the pelvic muscles

Second trimester

breast feeding?

2 a.

Involution occurs more rapidly

c.

White blood cells 8,000/mm3

b.

The incidence of allergies increases due to maternal

d.

One hour glucose challenge test 110 g/dL

antibodies

20. Which of the following characteristics of contractions

c.

d.

The father may resent the infant’s demands on the

would the nurse expect to find in a client

mother’s body

experiencing true labor?

There is a greater chance for error during preparation

a.

Occurring at irregular intervals

14. Which of the following would cause a false-positive

b.

Starting mainly in the abdomen

result on a pregnancy test?

c.

Gradually increasing intervals

The test was performed less than 10 days after an

d.

Increasing intensity with walking

abortion

21. During which of the following stages of labor

a.

b.

c.

d.

would the nurse assess “crowning”?

The test was performed too early or too late in the pregnancy

a.

First stage

The urine sample was stored too long at room

b.

Second stage

temperature

c.

Third stage

A spontaneous abortion or a missed abortion is

d.

Fourth stage

impending

22. Barbiturates are usually not given for pain

15. FHR can be auscultated with a fetoscope as early as

relief during active labor for which of the following

which of the following?

reasons?

a.

5 weeks gestation

a.

b.

10 weeks gestation

generalized drowsiness, and reluctance to feed for the

c.

15 weeks gestation

first few days.

d.

20 weeks gestation

b.

16. A client LMP began July 5. Her EDD should be which

The neonatal effects include hypotonia, hypothermia,

These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after

of the following?

intramuscular injection.

a.

January 2

c.

b.

March 28

antagonist make them generally inappropriate during

c.

April 12

labor.

d.

October 12

d.

17. Which of the following fundal heights indicates less

Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory

than 12 weeks’ gestation when the date of the LMP is unknown?

They rapidly transfer across the placenta, and lack of an

failure

23. Which of the following nursing interventions

a.

Uterus in the pelvis

would the nurse perform during the third stage of

b.

Uterus at the xiphoid

labor?

c.

Uterus in the abdomen

a.

Obtain a urine specimen and other laboratory tests.

d.

Uterus at the umbilicus

b.

Assess uterine contractions every 30 minutes.

c.

Coach for effective client pushing

reported promptly during the antepartum period?

d.

Promote parent-newborn interaction.

a.

Constipation

24. Which of the following actions demonstrates the

b.

Breast tenderness

nurse’s understanding about the newborn’s

c.

Nasal stuffiness

thermoregulatory ability?

d.

Leaking amniotic fluid

18. Which of the following danger signs should be

a.

Placing the newborn under a radiant warmer.

b.

Suctioning with a bulb syringe

would the nurse consider as significant?

c.

Obtaining an Apgar score

a.

Hematocrit 33.5%

d.

Inspecting the newborn’s umbilical cord

b.

Rubella titer less than 1:8

19. Which of the following prenatal laboratory test values

3 25. Immediately before expulsion, which of the following

stroked upward from the ball of the heel and across the

cardinal movements occur?

ball of the foot.

a.

Descent

b.

b.

Flexion

begin to cry when exposed to sudden movement or loud

c.

Extension

noise.

d.

External rotation

c.

26. Before birth, which of the following structures

The newborn abducts and flexes all extremities and may

The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or

connects the right and left auricles of the heart?

corner of mouth is touched.

a.

Umbilical vein

d.

b.

Foramen ovale

arms and legs when he is placed on his abdomen on a

c.

Ductus arteriosus

flat surface

d.

Ductus venosus

32. Which of the following statements best describes

27. Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?

The newborn will attempt to crawl forward with both

hyperemesis gravidarum? a.

Severe anemia leading to electrolyte, metabolic, and

a.

Mucus

nutritional imbalances in the absence of other medical

b.

Uric acid crystals

problems.

c.

Bilirubin

d.

Excess iron

b.

metabolic, and nutritional imbalances in the absence of

28. When assessing the newborn’s heart rate, which of the following ranges would be considered normal if

a. b. c. d.

other medical problems. c.

b.

c.

d.

Loss of appetite and continuous vomiting that commonly

the newborn were sleeping?

results in dehydration and ultimately decreasing

80 beats per minute

maternal nutrients

100 beats per minute

d.

Severe nausea and diarrhea that can cause

120 beats per minute

gastrointestinal irritation and possibly internal bleeding

140 beats per minute

33. Which of the following would the nurse identify as a

29. Which of the following is true regarding the fontanels

a.

Severe nausea and vomiting leading to electrolyte,

classic sign of PIH?

of the newborn?

a.

Edema of the feet and ankles

The anterior is triangular shaped; the posterior is

b.

Edema of the hands and face

diamond shaped.

c.

Weight gain of 1 lb/week

The posterior closes at 18 months; the anterior closes at

d.

Early morning headache

8 to 12 weeks.

34. In which of the following types of spontaneous

The anterior is large in size when compared to the

abortions would the nurse assess dark brown vaginal

posterior fontanel.

discharge and a negative pregnancy tests?

The anterior is bulging; the posterior appears sunken.

a.

Threatened

30. Which of the following groups of newborn reflexes

b.

Imminent

below are present at birth and remain unchanged

c.

Missed

through adulthood?

d.

Incomplete

a.

Blink, cough, rooting, and gag

35. Which of the following factors would the nurse

b.

Blink, cough, sneeze, gag

c.

Rooting, sneeze, swallowing, and cough

a.

Multiple gestation

d.

Stepping, blink, cough, and sneeze

b.

Uterine anomalies

31. Which of the following describes the Babinski reflex?

c.

Abdominal trauma

a.

The newborn’s toes will hyperextend and fan apart from

d.

Renal or vascular disease

dorsiflexion of the big toe when one side of foot is

36. Which of the following would the nurse assess in a

suspect as predisposing a client to placenta previa?

client experiencing abruptio placenta?

4 a.

Bright red, painless vaginal bleeding

b.

Concealed or external dark red bleeding

c.

Palpable fetal outline

d.

Soft and nontender abdomen

37. Which of the following is described as premature

b.

infection c.

Nursing care is based on fetal viability and gestational age.

d.

separation of a normally implanted placenta during the second half of pregnancy, usually with severe

PROM removes the fetus most effective defense against

PROM is associated with malpresentation and possibly incompetent cervix

42. Which of the following factors is the underlying cause

hemorrhage?

of dystocia?

a.

Placenta previa

a.

Nurtional

b.

Ectopic pregnancy

b.

Mechanical

c.

Incompetent cervix

c.

Environmental

d.

Abruptio placentae

d.

Medical

38. Which of the following may happen if the uterus

43. When uterine rupture occurs, which of the following

becomes overstimulated by oxytocin during the

would be the priority?

induction of labor?

a.

Limiting hypovolemic shock

a.

Weak contraction prolonged to more than 70 seconds

b.

Obtaining blood specimens

b.

Tetanic contractions prolonged to more than 90 seconds

c.

Instituting complete bed rest

c.

Increased pain with bright red vaginal bleeding

d.

Inserting a urinary catheter

d.

Increased restlessness and anxiety

44. Which of the following is the nurse’s initial action

39. When preparing a client for cesarean delivery, which

a.

b.

c.

when umbilical cord prolapse occurs?

of the following key concepts should be considered

a.

Begin monitoring maternal vital signs and FHR

when implementing nursing care?

b.

Place the client in a knee-chest position in bed

Instruct the mother’s support person to remain in the

c.

Notify the physician and prepare the client for delivery

family lounge until after the delivery

d.

Apply a sterile warm saline dressing to the exposed cord

Arrange for a staff member of the anesthesia

45. Which of the following amounts of blood loss

department to explain what to expect postoperatively

following birth marks the criterion for describing

Modify preoperative teaching to meet the needs of either

postpartum hemorrhage?

a planned or emergency cesarean birth

a.

More than 200 ml

Explain the surgery, expected outcome, and kind of

b.

More than 300 ml

anesthetics

c.

More than 400 ml

40. Which of the following best describes preterm labor?

d.

More than 500 ml

a.

46. Which of the following is the primary predisposing

d.

Labor that begins after 20 weeks gestation and before

factor related to mastitis?

37 weeks gestation b.

Labor that begins after 15 weeks gestation and before

a.

37 weeks gestation c.

Labor that begins after 24 weeks gestation and before

the lactiferous glands and ducts b.

28 weeks gestation d.

Labor that begins after 28 weeks gestation and before

c.

a.

d.

Breast injury caused by overdistention, stasis, and cracking of the nipples

47. Which of the following best describes thrombophlebitis?

The chorion and amnion rupture 4 hours before the onset of labor.

Temporary urinary retention due to decreased perception of the urge to avoid

evidence of the nurse’s understanding of the client’s immediate needs?

Endemic infection occurring randomly and localizing in the periglandular connective tissue

40 weeks gestation

41. When PROM occurs, which of the following provides

Epidemic infection from nosocomial sources localizing in

a.

Inflammation and clot formation that result when blood components combine to form an aggregate body

5 b.

c.

Inflammation and blood clots that eventually become

disturbance is most appropriate. Fear, pain, and

lodged within the pulmonary blood vessels

ineffective family coping also may be present but as

Inflammation and blood clots that eventually become

secondary nursing diagnoses.

lodged within the femoral vein d.

3.

B. Pressure and irritation of the bladder by the

Inflammation of the vascular endothelium with clot

growing uterus during the first trimester is

formation on the vessel wall

responsible for causing urinary frequency. Dysuria,

48. Which of the following assessment findings would the

incontinence, and burning are symptoms associated

nurse expect if the client develops DVT?

with urinary tract infections.

4.

C. During the second trimester, the reduction in

a.

Midcalf pain, tenderness and redness along the vein

b.

Chills, fever, malaise, occurring 2 weeks after delivery

gastric acidity in conjunction with pressure from the

c.

Muscle pain the presence of Homans sign, and swelling

growing uterus and smooth muscle relaxation, can

in the affected limb

cause heartburn and flatulence. HCG levels increase

Chills, fever, stiffness, and pain occurring 10 to 14 days

in the first, not the second, trimester. Decrease

after delivery

intestinal motility would most likely be the cause of

d.

49. Which of the following are the most commonly

constipation and bloating. Estrogen levels decrease in

assessed findings in cystitis? a.

b.

c.

d.

Frequency, urgency, dehydration, nausea, chills, and

the second trimester.

5.

flank pain

an irregular hyperpigmented area found on the face.

Nocturia, frequency, urgency dysuria, hematuria, fever

It is not seen on the breasts, areola, nipples, chest,

and suprapubic pain

neck, arms, legs, abdomen, or thighs.

Dehydration, hypertension, dysuria, suprapubic pain,

6.

relaxation of the pelvic joints, resulting in the typical

High fever, chills, flank pain nausea, vomiting, dysuria,

“waddling” gait. Changes in posture are related to

and frequency

the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the growing

reported postpartum “blues”?

b.

c.

d.

Between 10% and 40% of all new mothers report some

uterus. Weight gain has no effect on gait.

7.

2.

C. The average amount of weight gained during

form of postpartum blues

pregnancy is 24 to 30 lb. This weight gain consists of

Between 30% and 50% of all new mothers report some

the following: fetus – 7.5 lb; placenta and membrane

form of postpartum blues

– 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb;

Between 50% and 80% of all new mothers report some

breasts – 3 lb; and increased blood volume – 2 to 4

form of postpartum blues

lb; extravascular fluid and fat – 4 to 9 lb. A gain of

Between 25% and 70% of all new mothers report some

12 to 22 lb is insufficient, whereas a weight gain of

form of postpartum blues

15 to 25 lb is marginal. A weight gain of 25 to 40 lb

View Answers and Rationale

is considered excessive.

8. 1.

C. During pregnancy, hormonal changes cause

chills, and fever

50. Which of the following best reflects the frequency of

a.

D. Chloasma, also called the mask of pregnancy, is

C. Pressure of the growing uterus on blood vessels

B. Although all of the factors listed are important,

results in an increased risk for venous stasis in the

sperm motility is the most significant criterion when

lower extremities. Subsequently, edema and varicose

assessing male infertility. Sperm count, sperm

vein formation may occur. Thrombophlebitis is an

maturity, and semen volume are all significant, but

inflammation of the veins due to thrombus

they are not as significant sperm motility.

formation. Pregnancy-induced hypertension is not

D. Based on the partner’s statement, the couple is

associated with these symptoms. Gravity plays only a

verbalizing feelings of inadequacy and negative

minor role with these symptoms.

feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem

9.

C. Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.

6 Probable signs are objective findings that strongly

with bottle feeding. No preparation is required for

suggest pregnancy. Other probable signs include

breast feeding.

Hegar sign, which is softening of the lower uterine

14. A. A false-positive reaction can occur if the

segment; Piskacek sign, which is enlargement and

pregnancy test is performed less than 10 days after

softening of the uterus; serum laboratory tests;

an abortion. Performing the tests too early or too late

changes in skin pigmentation; and ultrasonic

in the pregnancy, storing the urine sample too long

evidence of a gestational sac. Presumptive signs are

at room temperature, or having a spontaneous or

subjective signs and include amenorrhea; nausea

missed abortion impending can all produce false-

and vomiting; urinary frequency; breast tenderness

negative results.

and changes; excessive fatigue; uterine enlargement; and quickening.

10. B. Presumptive signs of pregnancy are subjective

15. D. The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is ausculatated at the midline suprapubic region with

signs. Of the signs listed, only nausea and vomiting

Doppler ultrasound transducer at 10 to 12 week’s

are presumptive signs. Hegar sign, skin

gestation. FHR, cannot be heard any earlier than 10

pigmentation changes, and a positive serum

weeks’ gestation.

pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.

11. D. During the first trimester, common emotional

16. C. To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1

reactions include ambivalence, fear, fantasies, or

year (if applicable) to arrive at the EDD as follows: 5

anxiety. The second trimester is a period of well-

+ 7 = 12 (July) minus 3 = 4 (April). Therefore, the

being accompanied by the increased need to learn

client’s EDD is April 12.

about fetal growth and development. Common

17. A. When the LMP is unknown, the gestational age of

emotional reactions during this trimester include

the fetus is estimated by uterine size or position

narcissism, passivity, or introversion. At times the

(fundal height). The presence of the uterus in the

woman may seem egocentric and self-centered.

pelvis indicates less than 12 weeks’ gestation. At

During the third trimester, the woman typically feels

approximately 12 to 14 weeks, the fundus is out of

awkward, clumsy, and unattractive, often becoming

the pelvis above the symphysis pubis. The fundus is

more introverted or reflective of her own childhood.

at the level of the umbilicus at approximately 20

12. B. First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and

weeks’ gestation and reaches the xiphoid at term or 40 weeks.

18. D. Danger signs that require prompt reporting

nutrition. Some early classes may include pregnant

leaking of amniotic fluid, vaginal bleeding, blurred

couples. Second and third trimester classes may

vision, rapid weight gain, and elevated blood

focus on preparation for birth, parenting, and

pressure. Constipation, breast tenderness, and nasal

newborn care.

stuffiness are common discomforts associated with

13. C. With breast feeding, the father’s body is not capable of providing the milk for the newborn, which

pregnancy.

19. B. A rubella titer should be 1:8 or greater. Thurs, a

may interfere with feeding the newborn, providing

finding of a titer less than 1:8 is significant,

fewer chances for bonding, or he may be jealous of

indicating that the client may not possess immunity

the infant’s demands on his wife’s time and body.

to rubella. A hematocrit of 33.5% a white blood cell

Breast feeding is advantageous because uterine

count of 8,000/mm3, and a 1 hour glucose challenge

involution occurs more rapidly, thus minimizing blood

test of 110 g/dl are with normal parameters.

loss. The presence of maternal antibodies in breast

20. D. With true labor, contractions increase in intensity

milk helps decrease the incidence of allergies in the

with walking. In addition, true labor contractions

newborn. A greater chance for error is associated

occur at regular intervals, usually starting in the back

7 and sweeping around to the abdomen. The interval of

to extrauterine life. Inspecting the umbilical cord aids

true labor contractions gradually shortens.

in detecting cord anomalies.

21. B. Crowing, which occurs when the newborn’s head

25. D. Immediately before expulsion or birth of the rest

or presenting part appears at the vaginal opening,

of the body, the cardinal movement of external

occurs during the second stage of labor. During the

rotation occurs. Descent flexion, internal rotation,

first stage of labor, cervical dilation and effacement

extension, and restitution (in this order) occur before

occur. During the third stage of labor, the newborn

external rotation.

and placenta are delivered. The fourth stage of labor

26. B. The foramen ovale is an opening between the

lasts from 1 to 4 hours after birth, during which time

right and left auricles (atria) that should close shortly

the mother and newborn recover from the physical

after birth so the newborn will not have a murmur or

process of birth and the mother’s organs undergo the

mixed blood traveling through the vascular system.

initial readjustment to the nonpregnant state.

The umbilical vein, ductus arteriosus, and ductus

22. C. Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist makes

venosus are obliterated at birth.

27. B. Uric acid crystals in the urine may produce the

them generally inappropriate during active labor.

reddish “brick dust” stain on the diaper. Mucus would

Neonatal side effects of barbiturates include central

not produce a stain. Bilirubin and iron are from

nervous system depression, prolonged drowsiness,

hepatic adaptation.

delayed establishment of feeding (e.g. due to poor

28. B. The normal heart rate for a newborn that is

sucking reflex or poor sucking pressure).

sleeping is approximately 100 beats per minute. If

Tranquilizers are associated with neonatal effects

the newborn was awake, the normal heart rate would

such as hypotonia, hypothermia, generalized

range from 120 to 160 beats per minute.

drowsiness, and reluctance to feed for the first few

29. C. The anterior fontanel is larger in size than the

days. Narcotic analgesic readily cross the placental

posterior fontanel. Additionally, the anterior fontanel,

barrier, causing depressive effects in the newborn 2

which is diamond shaped, closes at 18 months,

to 3 hours afterintramuscular injection. Regional

whereas the posterior fontanel, which is triangular

anesthesia is associated with adverse reactions such

shaped, closes at 8 to 12 weeks. Neither fontanel

as maternal hypotension, allergic or toxic reaction, or

should appear bulging, which may indicate increased

partial or total respiratory failure.

intracranial pressure, or sunken, which may indicate

23. D. During the third stage of labor, which begins with the delivery of the newborn, the nurse would

dehydration.

30. B. Blink, cough, sneeze, swallowing and gag reflexes

promote parent-newborn interaction by placing the

are all present at birth and remain unchanged

newborn on the mother’s abdomen and encouraging

through adulthood. Reflexes such as rooting and

the parents to touch the newborn. Collecting a urine

stepping subside within the first year.

specimen and other laboratory tests is done on

31. A. With the babinski reflex, the newborn’s toes

admission during the first stage of labor. Assessing

hyperextend and fan apart from dorsiflexion of the

uterine contractions every 30 minutes is performed

big toe when one side of foot is stroked upward form

during the latent phase of the first stage of labor.

the heel and across the ball of the foot. With the

Coaching the client to push effectively is appropriate

startle reflex, the newborn abducts and flexes all

during the second stage of labor.

extremities and may begin to cry when exposed to

24. A. The newborn’s ability to regulate body

sudden movement of loud noise. With the rooting

temperature is poor. Therefore, placing the newborn

and sucking reflex, the newborn turns his head in the

under a radiant warmer aids in maintaining his or her

direction of stimulus, opens the mouth, and begins to

body temperature. Suctioning with a bulb syringe

suck when the cheeks, lip, or corner of mouth is

helps maintain a patent airway. Obtaining an Apgar

touched. With the crawl reflex, the newborn will

score measures the newborn’s immediate adjustment

8 attempt to crawl forward with both arms and legs

hemorrhage. Placenta previa refers to implantation of

when he is placed on his abdomen on a flat surface.

the placenta in the lower uterine segment, causing

32. B. The description of hyperemesis gravidarum

painless bleeding in the third trimester of pregnancy.

includes severe nausea and vomiting, leading to

Ectopic pregnancy refers to the implantation of the

electrolyte, metabolic, and nutritional imbalances in

products of conception in a site other than the

the absence of other medical problems. Hyperemesis

endometrium. Incompetent cervix is a conduction

is not a form of anemia. Loss of appetite may occur

characterized by painful dilation of the cervical os

secondary to the nausea and vomiting of

without uterine contractions.

hyperemesis, which, if it continues, can deplete the

38. B. Hyperstimulation of the uterus such as with

nutrients transported to the fetus. Diarrhea does not

oxytocin during the induction of labor may result in

occur with hyperemesis.

tetanic contractions prolonged to more than

33. B. Edema of the hands and face is a classic sign of

90seconds, which could lead to such complications as

PIH. Many healthy pregnant woman experience foot

fetal distress, abruptio placentae, amniotic fluid

and ankle edema. A weight gain of 2 lb or more per

embolism, laceration of the cervix, and uterine

week indicates a problem. Early morning headache is

rupture. Weak contractions would not occur. Pain,

not a classic sign of PIH.

bright red vaginal bleeding, and increased

34. C. In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelled. The cervix remains closed; there may

restlessness and anxiety are not associated with hyperstimulation.

39. C. A key point to consider when preparing the client

be a dark brown vaginal discharge, negative

for a cesarean delivery is to modify the preoperative

pregnancy test, and cessation of uterine growth and

teaching to meet the needs of either a planned or

breast tenderness. A threatened abortion is

emergency cesarean birth, the depth and breadth of

evidenced with cramping and vaginal bleeding in

instruction will depend on circumstances and time

early pregnancy, with no cervical dilation. An

available. Allowing the mother’s support person to

incomplete abortion presents with bleeding,

remain with her as much as possible is an important

cramping, and cervical dilation. An incomplete

concept, although doing so depends on many

abortion involves only expulsion of part of the

variables. Arranging for necessary explanations by

products of conception and bleeding occurs with

various staff members to be involved with the client’s

cervical dilation.

care is a nursing responsibility. The nurse is

35. A. Multiple gestation is one of the predisposing

responsible for reinforcing the explanations about the

factors that may cause placenta previa. Uterine

surgery, expected outcome, and type of anesthetic to

anomalies abdominal trauma, and renal or vascular

be used. The obstetrician is responsible for

disease may predispose a client to abruptio

explaining about the surgery and outcome and the

placentae.

anesthesiology staff is responsible for explanations

36. B. A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting

about the type of anesthesia to be used.

40. A. Preterm labor is best described as labor that

sudden intense localized uterine pain. The uterus is

begins after 20 weeks’ gestation and before 37

typically firm to boardlike, and the fetal presenting

weeks’ gestation. The other time periods are

part may be engaged. Bright red, painless vaginal

inaccurate.

bleeding, a palpable fetal outline and a soft

41. B. PROM can precipitate many potential and actual

nontender abdomen are manifestations of placenta

problems; one of the most serious is the fetus loss of

previa.

an effective defense against infection. This is the

37. D. Abruptio placentae is described as premature

client’s most immediate need at this time. Typically,

separation of a normally implanted placenta during

PROM occurs about 1 hour, not 4 hours, before labor

the second half of pregnancy, usually with severe

begins. Fetal viability and gestational age are less

9 immediate considerations that affect the plan of care.

vasculature refers to pulmonary embolism; in the

Malpresentation and an incompetent cervix may be

femoral vein, femoral thrombophlebitis.

causes of PROM.

42. B. Dystocia is difficult, painful, prolonged labor due

48. C. Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the

to mechanical factors involving the fetus

affected limb. Midcalf pain, tenderness, and redness,

(passenger), uterus (powers), pelvis (passage), or

along the vein reflect superficial thrombophlebitis.

psyche. Nutritional, environment, and medical factors

Chills, fever and malaise occurring 2 weeks after

may contribute to the mechanical factors that cause

delivery reflect pelvic thrombophlebitis. Chills, fever,

dystocia.

stiffness and pain occurring 10 to 14 days after

43. A. With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to

delivery suggest femoral thrombophlebitis.

49. B. Manifestations of cystitis include, frequency,

prevent and limit hypovolemic shock. Immediate

urgency, dysuria, hematuria nocturia, fever, and

steps should include giving oxygen, replacing lost

suprapubic pain. Dehydration, hypertension, and

fluids, providing drug therapy as needed, evaluating

chills are not typically associated with cystitis. High

fetal responses and preparing for surgery. Obtaining

fever chills, flank pain, nausea, vomiting, dysuria,

blood specimens, instituting complete bed rest, and

and frequency are associated with pvelonephritis.

inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture.

44. B. The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.

45. D. Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage.

46. D. With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the primary predisposing factor. Epidemic and endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis.

47. D. Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. Blood components combining to form an aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary

50. C. According to statistical reports, between 50% and 80% of all new mothers report some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect.

10 Maternity-Nsg Practice Test Part 2 1.

For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following?

a.

Decrease the incidence of nausea

b.

Maintain hormonal levels

c.

Reduce side effects

d. 2.

Prevent drug interactions When teaching a client about contraception. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections?

a.

Spermicides

b.

Diaphragm

c.

Condoms

d.

Vasectomy

3.

When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided?

a.

Diaphragm

b.

Female condom

c. d. 4.

Oral contraceptives Rhythm method For which of the following clients would the nurse expect that an intrauterine device would not be recommended?

a.

Woman over age 35

b.

Nulliparous woman

c.

Promiscuous young adult

d.

Postpartum client

5.

A client in her third trimester tells the nurse, “I’m constipated all the time!” Which of the following should the nurse recommend?

a.

Daily enemas

b.

Laxatives

c.

Increased fiber intake

d.

Decreased fluid intake

6.

Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy?

a.

10 pounds per trimester

b.

1 pound per week for 40 weeks

11 12. A client 12 weeks’ pregnant come to the

c.

½ pound per week for 40 weeks

d.

A total gain of 25 to 30 pounds

emergency department with abdominal cramping

7.

The client tells the nurse that her last menstrual

and moderate vaginal bleeding. Speculum

period started on January 14 and ended on

examination reveals 2 to 3 cms cervical dilation.

January 20. Using Nagele’s rule,

The nurse would document these findings as

the nurse determines her EDD to be which of the

which of the following?

following?

a.

Threatened abortion

a.

September 27

b.

Imminent abortion

b.

October 21

c.

Complete abortion

c.

November 7

d.

Missed abortion

d.

December 27

13. Which of the following would be the priority

8.

When taking an obstetrical history on a pregnant

nursing diagnosis for a client with an ectopic

client who states, “I had a son born at 38 weeks

pregnancy?

gestation, a daughter born at 30 weeks gestation

a.

Risk for infection

and I lost a baby at about 8 weeks,”

b.

Pain

the nurse should record her obstetrical history as

c.

Knowledge Deficit

which of the following?

d.

Anticipatory Grieving

a.

G2 T2 P0 A0 L2

14. Before assessing the postpartum client’s uterus

b.

G3 T1 P1 A0 L2

for firmness and position in relation to the

c.

G3 T2 P0 A0 L2

umbilicus and midline, which of the following

d.

G4 T1 P1 A1 L2

should the nurse do first?

9.

When preparing to listen to the fetal heart rate at

a.

Assess the vital signs

12 weeks’ gestation, the nurse would use which of

b.

Administer analgesia

the following?

c.

Ambulate her in the hall

a.

Stethoscope placed midline at the umbilicus

d.

Assist her to urinate

b.

Doppler placed midline at the suprapubic region

15. Which of the following should the nurse do when a

c.

Fetoscope placed midway between the umbilicus

primipara who is lactating tells the nurse that she

and the xiphoid process

has sore nipples?

d.

External electronic fetal monitor placed at the

a.

Tell her to breast feed more frequently

umbilicus

b.

Administer a narcotic before breast feeding

10. When developing a plan of care for a client newly

c.

Encourage her to wear a nursing brassiere

diagnosed with gestational diabetes, which of the

d.

Use soap and water to clean the nipples

following instructions would be the priority?

16. The nurse assesses the vital signs of a client, 4

a.

Dietary intake

hours’ postpartum that are as follows: BP 90/60;

b.

Medication

temperature 100.4ºF; pulse 100 weak, thready; R

c.

Exercise

20 per minute. Which of the following should

d.

Glucose monitoring

the nursedo first?

11. A client at 24 weeks gestation has gained 6

a.

Report the temperature to the physician

pounds in 4 weeks. Which of the following would

b.

Recheck the blood pressure with another cuff

be the priority when assessing the client?

c.

Assess the uterus for firmness and position

a.

Glucosuria

d.

Determine the amount of lochia

b.

Depression

17. The nurse assesses the postpartum

c.

Hand/face edema

vaginal discharge (lochia) on four clients. Which of

d.

Dietary intake

the following assessments would warrant notification of the physician?

12 a. b. c.

A dark red discharge on a 2-day postpartum client

23. The mother asks the nurse. “What’s wrong with

A pink to brownish discharge on a client who is 5

my son’s breasts? Why are they so enlarged?”

days postpartum

Whish of the following would be the best response

Almost colorless to creamy discharge on a client 2

by the nurse?

weeks after delivery

d. A bright red discharge 5 days after delivery 18. A postpartum client has a temperature of 101.4ºF,

a.

experienced with birth” b.

with a uterus that is tender when palpated, remains unusually large, and not descending as

“A decrease in material hormones present before birth causes enlargement,”

c.

normally expected. Which of the following should the nurseassess next?

“The breast tissue is inflamed from the trauma

“You should discuss this with your doctor. It could be a malignancy”

d.

“The tissue has hypertrophied while the baby was

a.

Lochia

in the uterus”

b.

Breasts

c.

Incision

following on a male newborn: respirations 78;

d.

Urine

apical hearth rate 160 BPM, nostril flaring; mild

24. Immediately after birth the nurse notes the

19. Which of the following is the priority focus of

intercostal retractions; and grunting at the end of

nursing practice with the current early

expiration. Which of the following should

postpartumdischarge?

the nurse do?

a.

Promoting comfort and restoration of health

b.

Exploring the emotional status of the family

c.

Facilitating safe and effective self-and newborn

b.

Start oxygen per nasal cannula at 2 L/min.

care

c.

Suction the infant’s mouth and nares

Teaching about the importance of family planning

d.

Recognize this as normal first period of reactivity

d.

20. Which of the following actions would be

a.

Call the assessment data to the physician’s attention

25. The nurse hears a mother telling a friend on the

least effective in maintaining a neutral thermal

telephone about umbilical cord care. Which of the

environment for the newborn?

following statements by the mother indicates

a.

Placing infant under radiant warmer after bathing

effective teaching?

b.

Covering the scale with a warmed blanket prior to

a.

“Daily soap and water cleansing is best”

weighing

b.

‘Alcohol helps it dry and kills germs”

Placing crib close to nursery window for family

c.

“An antibiotic ointment applied daily prevents

c.

viewing d.

Covering the infant’s head with a knit stockinette

21. A newborn who has an asymmetrical Moro reflex

infection” d.

“He can have a tub bath each day”

26. A newborn weighing 3000 grams and feeding

response should be further assessed for which of

every 4 hours needs 120 calories/kg of body

the following?

weight every 24 hours for proper growth and

a.

Talipes equinovarus

development. How many ounces of 20 cal/oz

b.

Fractured clavicle

formula should this newborn receive at each

c.

Congenital hypothyroidism

feeding to meet nutritional needs?

d.

Increased intracranial pressure

a.

2 ounces

b.

3 ounces

assessing for which of the following is the priority?

c.

4 ounces

a.

Infection

d.

6 ounces

b.

Hemorrhage

27. The postterm neonate with meconium-

c.

Discomfort

stained amniotic fluid needs care designed to

d.

Dehydration

especially monitor for which of the following?

22. During the first 4 hours after a male circumcision,

13 a.

Respiratory problems

33. To differentiate as a female, the hormonal

b.

Gastrointestinal problems

stimulation of the embryo that must occur

c.

Integumentary problems

involves which of the following?

d.

Elimination problems

a.

Increase in maternal estrogen secretion

b.

Decrease in maternal androgen secretion

the following techniques denotes the correct

c.

Secretion of androgen by the fetal gonad

method of measurement used by the nurse?

d.

Secretion of estrogen by the fetal gonad

a.

From the xiphoid process to the umbilicus

34. A client at 8 weeks’ gestation calls complaining of

b.

From the symphysis pubis to the xiphoid process

slight nausea in the morning hours. Which of the

c.

From the symphysis pubis to the fundus

following client interventions should the nurse

d.

From the fundus to the umbilicus

question?

28. When measuring a client’s fundal height, which of

29. A client with severe preeclampsia is admitted with

a.

of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most

Taking 1 teaspoon of bicarbonate of soda in an 8ounce glass of water

b.

important to include in the client’s plan of care?

Eating a few low-sodium crackers before getting out of bed

a.

Daily weights

c.

Avoiding the intake of liquids in the morning hours

b.

Seizure precautions

d.

Eating six small meals a day instead of thee large

c.

Right lateral positioning

d.

Stress reduction

meals 35. The nurse documents positive ballottement in the

30. A postpartum primipara asks the nurse, “When

client’s prenatal record. The nurse understands

can we have sexual intercourse again?” Which of

that this indicates which of the following?

the following would be the nurse’s best response?

a.

Palpable contractions on the abdomen

a.

“Anytime you both want to.”

b.

Passive movement of the unengaged fetus

b.

“As soon as choose a contraceptive method.”

c.

Fetal kicking felt by the client

c.

“When the discharge has stopped and the incision

d.

Enlargement and softening of the uterus

is healed.”

36. During a pelvic exam the nurse notes a purple-

d.

“After your 6 weeks examination.”

blue tinge of the cervix. The nurse documents this

31. When preparing to administer the vitamin K

as which of the following?

injection to a neonate, the nurse would select

a.

Braxton-Hicks sign

which of the following sites as appropriate for the

b.

Chadwick’s sign

injection?

c.

Goodell’s sign

a.

Deltoid muscle

d.

McDonald’s sign

b.

Anterior femoris muscle

37. During a prenatal class, the nurse explains the

c.

Vastus lateralis muscle

rationale for breathing techniques during

d.

Gluteus maximus muscle

preparation for labor based on the understanding

32. When performing a pelvic examination, the nurse

that breathing techniques are most important in

observes a red swollen area on the right side of the vaginal orifice. The nurse would document this

achieving which of the following? a.

as enlargement of which of the following? a.

Clitoris

b.

Parotid gland

c.

Skene’s gland

d.

Bartholin’s gland

Eliminate pain and give the expectant parents something to do

b.

Reduce the risk of fetal distress by increasing uteroplacental perfusion

c.

Facilitate relaxation, possibly reducing the perception of pain

d.

Eliminate pain so that less analgesia and anesthesia are needed

14 38. After 4 hours of active labor, the nurse notes that

d.

the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the

Above the maternal umbilicus and to the left of midline

43. The amniotic fluid of a client has a greenish tint.

following would the nurse anticipate doing?

The nurse interprets this to be the result of which

a.

Obtaining an order to begin IV oxytocin infusion

of the following?

b.

Administering a light sedative to allow the patient

a.

Lanugo

to rest for several hour

b.

Hydramnio

Preparing for a cesarean section for failure to

c.

Meconium

progress

d.

Vernix

Increasing the encouragement to the patient when

44. A patient is in labor and has just been told she has

c.

d.

pushing begins

a breech presentation. The nurse should be

39. A multigravida at 38 weeks’ gestation is admitted

particularly alert for which of the following?

with painless, bright red bleeding and mild

a.

Quickening

contractions every 7 to 10 minutes. Which of the

b.

Ophthalmia neonatorum

following assessments should be avoided?

c.

Pica

a.

Maternal vital sign

d.

Prolapsed umbilical cord

b.

Fetal heart rate

45. When describing dizygotic twins to a couple, on

c.

Contraction monitoring

which of the following would the nurse base the

d.

Cervical dilation

explanation?

40. Which of the following would be the nurse’s most

a.

a.

Two ova fertilized by separate sperm

appropriate response to a client who asks why she

b.

Sharing of a common placenta

must have a cesarean delivery if she has a

c.

Each ova with the same genotype

complete placenta previa?

d.

Sharing of a common chorion

“You will have to ask your physician when he

46. Which of the following refers to the single cell that

returns.”

reproduces itself after conception?

b.

“You need a cesarean to prevent hemorrhage.”

a.

Chromosome

c.

“The placenta is covering most of your cervix.”

b.

Blastocyst

d.

“The placenta is covering the opening of the

c.

Zygote

uterus and blocking your baby.”

d.

Trophoblast

41. The nurse understands that the fetal head is in

47. In the late 1950s, consumers and health care

which of the following positions with a face

professionals began challenging the routine use of

presentation?

analgesics and anesthetics during childbirth.

a.

Completely flexed

Which of the following was an outgrowth of this

b.

Completely extended

concept?

c.

Partially extended

a.

Labor, delivery, recovery, postpartum (LDRP)

d.

Partially flexed

b.

Nurse-midwifery

c.

Clinical nurse specialist

presentation, the nurse would expect the fetal

d.

Prepared childbirth

heart rate would be most audible in which of the

48. A client has a midpelvic contracture from a

42. With a fetus in the left-anterior breech

following areas?

previous pelvic injury due to a motor vehicle

Above the maternal umbilicus and to the right of

accident as a teenager. The nurse is aware that

midline

this could prevent a fetus from passing through or

b.

In the lower-left maternal abdominal quadrant

around which structure during childbirth?

c.

In the lower-right maternal abdominal quadrant

a.

a.

Symphysis pubis

b.

Sacral promontory

15 c.

Ischial spines

spermatozoa from the ejaculate, but it does not

d.

Pubic arch

eliminate bacterial and/or viral microorganisms

49. When teaching a group of adolescents about variations in the length of the menstrual cycle, the

that can cause sexually transmitted infections.

3.

A. The diaphragm must be fitted individually to

nurse understands that the underlying mechanism

ensure effectiveness. Because of the changes to

is due to variations in which of the following

the reproductive structures during pregnancy and

phases?

following delivery, the diaphragm must be refitted,

a.

Menstrual phase

usually at the 6 weeks’ examination following

b.

Proliferative phase

childbirth or after a weight loss of 15 lbs or more.

c.

Secretory phase

In addition, for maximum effectiveness,

d.

Ischemic phase

spermicidal jelly should be placed in the dome and

50. When teaching a group of adolescents about male

around the rim. However, spermicidal jelly should

hormone production, which of the following would

not be inserted into the vagina until involution is

the nurse include as being produced by the Leydig

completed at approximately 6 weeks. Use of

cells?

a female condom protects the reproductive

a.

Follicle-stimulating hormone

system from the introduction of semen or

b.

Testosterone

spermicides into the vagina and may be used after

c.

Leuteinizing hormone

childbirth. Oral contraceptives may be started

d.

Gonadotropin releasing hormone

within the first postpartum week to ensure suppression of ovulation. For the couple who has determined the female’s fertile period, using the

1.

B. Regular timely ingestion of oral

rhythm method, avoidance of intercourse during

contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the

2.

this period, is safe and effective.

4.

C. An IUD may increase the risk of pelvic

hypothalamus and anterior pituitary leading to

inflammatory disease, especially in women with

inappropriate secretion of FSH and LH. Therefore,

more than one sexual partner, because of the

follicles do not mature, ovulation is inhibited, and

increased risk of sexually transmitted infections.

pregnancy is prevented. The estrogen content of

An UID should not be used if the woman has an

the oral site contraceptive may cause the nausea,

active or chronic pelvic infection, postpartum

regardless of when the pill is taken. Side effects

infection, endometrial hyperplasia or carcinoma,

and drug interactions may occur with oral

or uterine abnormalities. Age is not a factor in

contraceptives regardless of the time the pill is

determining the risks associated with IUD use.

taken.

Most IUD users are over the age of 30. Although

C. Condoms, when used correctly and

there is a slightly higher risk for infertility in

consistently, are the most effective contraceptive

women who have never been pregnant, the IUD is

method or barrier against bacterial and

an acceptable option as long as the risk-benefit

viral sexually transmitted infections. Although

ratio is discussed. IUDs may be inserted

spermicides kill sperm, they do not provide

immediately after delivery, but this is not

reliable protection against the spread of sexually

recommended because of the increased risk and

transmitted infections, especially intracellular

rate of expulsion at this time.

organisms such as HIV. Insertion and removal of

5.

C. During the third trimester, the enlarging uterus

the diaphragm along with the use of the

places pressure on the intestines. This coupled

spermicides may cause vaginal irritations, which

with the effect of hormones on smooth muscle

could place the client at risk for infection

relaxation causes decreased intestinal motility

transmission. Male sterilization eliminates

(peristalsis). Increasing fiber in the diet will help

16 fecal matter pass more quickly through the

preterm (P). Aspontaneous abortion occurred at 8

intestinal tract, thus decreasing the amount of

weeks (A). She has two living children (L).

water that is absorbed. As a result, stool is softer

6.

the pelvis and is palpable above the symphysis

preterm labor and/or electrolyte loss and should

pubis. The Doppler intensifies the sound of the

be avoided. Laxatives may cause preterm labor by

fetal pulse rate so it is audible. The uterus has

stimulating peristalsis and may interfere with the

merely risen out of the pelvis into the abdominal

absorption of nutrients. Use for more than 1 week

cavity and is not at the level of the umbilicus. The

can also lead to laxative dependency. Liquid in

fetal heart rate at this age is not audible with a

the diet helps provide a semisolid, soft

stethoscope. The uterus at 12 weeks is just above

consistency to the stool. Eight to ten glasses of

the symphysis pubis in the abdominal cavity, not

fluid per day are essential to maintain hydration

midway between the umbilicus and the xiphoid

and promote stool evacuation.

process. At 12 weeks the FHR would be difficult to

D. To ensure adequate fetal growth and

auscultate with a fetoscope. Although the external

development during the 40 weeks of a pregnancy,

electronic fetal monitor would project the FHR, the

a total weight gain 25 to 30 pounds is

uterus has not risen to the umbilicus at 12 weeks.

10. A. Although all of the choices are important in the

pounds by 30 weeks; and 27.5 pounds by 40

management of diabetes, diet therapy is the

weeks. The pregnant woman should gain less

mainstay of the treatment plan and should always

weight in the first and second trimesterthan in the

be the priority. Women diagnosed with gestational

third. During the first trimester, the client should

diabetesgenerally need only diet therapy without

only gain 1.5 pounds in the first 10 weeks, not 1

medication to control their blood sugar levels.

pound per week. A weight gain of ½ pound per

Exercise, is important for all pregnant women and

week would be 20 pounds for the total pregnancy,

especially for diabetic women, because it burns up

less than the recommended amount.

glucose, thus decreasing blood sugar. However,

B. To calculate the EDD by Nagele’s rule, add 7

dietary intake, not exercise, is the priority. All

days to the first day of the last menstrual period

pregnant women with diabetes should have

and count back 3 months, changing the year

periodic monitoring of serum glucose. However,

appropriately. To obtain a date of September 27, 7

those with gestational diabetesgenerally do not

days have been added to the last day of the LMP

need daily glucose monitoring. The standard of

(rather than the first day of the LMP), plus 4

care recommends a fasting and 2-hour

months (instead of 3 months) were counted back.

postprandial blood sugar level every 2 weeks.

To obtain the date of November 7, 7 days have

8.

B. At 12 weeks gestation, the uterus rises out of

and easier to pass. Enemas could precipitate

recommended: 1.5 pounds in the first 10 weeks; 9

7.

9.

11. C. After 20 weeks’ gestation, when there is a rapid

been subtracted (instead of added) from the first

weight gain, preeclampsia should be suspected,

day of LMP plus November indicates counting back

which may be caused by fluid retention

2 months (instead of 3 months) from January. To

manifested by edema, especially of the hands and

obtain the date of December 27, 7 days were

face. The three classic signs of preeclampsia are

added to the last day of the LMP (rather than the

hypertension, edema, and proteinuria. Although

first day of the LMP) and December indicates

urine is checked for glucose at each clinic visit,

counting back only 1 month (instead of 3 months)

this is not the priority. Depression may cause

from January.

either anorexia or excessive food intake, leading

D. The client has been pregnant four times,

to excessive weight gain or loss. This is not,

including current pregnancy (G). Birth at 38

however, the priority consideration at this time.

weeks’ gestation is considered full term (T), while

Weight gain thought to be caused by excessive

birth form 20 weeks to 38 weeks is considered

food intake would require a 24-hour diet recall.

17 However, excessive intake would not be the

cotton straps. This does not, however, prevent or

primary consideration for this client at this time.

reduce nipple soreness. Soaps are drying to the

12. B. Cramping and vaginal bleeding coupled with

skin of the nipples and should not be used on the

cervical dilation signifies that termination of the

breasts of lactating mothers. Dry nipple skin

pregnancy is inevitable and cannot be prevented.

predisposes to cracks and fissures, which can

Thus, the nurse would document an imminent

become sore and painful.

abortion. In a threatened abortion, cramping and

16. D. A weak, thready pulse elevated to 100 BPM

vaginal bleeding are present, but there is no

may indicate impending hemorrhagic shock. An

cervical dilation. The symptoms may subside or

increased pulse is a compensatory mechanism of

progress to abortion. In a complete abortion all the

the body in response to decreased fluid volume.

products of conception are expelled. A missed

Thus, the nurse should check the amount of lochia

abortion is early fetal intrauterine death without

present. Temperatures up to 100.48F in the first

expulsion of the products of conception.

24 hours after birth are related to the dehydrating

13. B. For the client with an ectopic pregnancy, lower

effects of labor and are considered normal.

abdominal pain, usually unilateral, is the primary

Although rechecking the blood pressure may be a

symptom. Thus, pain is the priority. Although the

correct choice of action, it is not the first action

potential for infection is always present, the risk is

that should be implemented in light of the other

low in ectopic pregnancy because pathogenic

data. The data indicate a potential impending

microorganisms have not been introduced from

hemorrhage. Assessing the uterus for firmness

external sources. The client may have a limited

and position in relation to the umbilicus and

knowledge of the pathology and treatment of the

midline is important, but the nurse should check

condition and will most likely experience grieving,

the extent of vaginal bleeding first. Then it would

but this is not the priority at this time.

be appropriate to check the uterus, which may be

14. D. Before uterine assessment is performed, it is essential that the woman empty her bladder. A full

a possible cause of the hemorrhage.

17. D. Any bright red vaginal discharge would be

bladder will interfere with the accuracy of the

considered abnormal, but especially 5 days after

assessment by elevating the uterus and displacing

delivery, when the lochia is typically pink to

to the side of the midline. Vital sign assessment is

brownish. Lochia rubra, a dark red discharge, is

not necessary unless an abnormality in uterine

present for 2 to 3 days after delivery. Bright red

assessment is identified. Uterine assessment

vaginal bleeding at this time suggests late

should not cause acute pain that requires

postpartum hemorrhage, which occurs after the

administration of analgesia. Ambulating the client

first 24 hours following delivery and is generally

is an essential component of postpartum care, but

caused by retained placental fragments or

is not necessary prior to assessment of the uterus.

bleeding disorders. Lochia rubra is the normal

15. A. Feeding more frequently, about every 2 hours,

dark red discharge occurring in the first 2 to 3

will decrease the infant’s frantic, vigorous sucking

days after delivery, containing epithelial cells,

from hunger and will decrease breast

erythrocyes, leukocytes and decidua. Lochia

engorgement, soften the breast, and promote

serosa is a pink to brownish serosanguineous

ease of correct latching-on for feeding. Narcotics

discharge occurring from 3 to 10 days after

administered prior to breast feeding are passed

delivery that contains decidua, erythrocytes,

through the breast milk to the infant, causing

leukocytes, cervical mucus, and microorganisms.

excessive sleepiness. Nipple soreness is not

Lochia alba is an almost colorless to yellowish

severe enough to warrant narcotic analgesia. All

discharge occurring from 10 days to 3 weeks after

postpartum clients, especially lactating mothers,

delivery and containing leukocytes, decidua,

should wear a supportive brassiere with wide

18 epithelial cells, fat, cervical mucus, cholesterol

are not involved with the Moro reflex.

crystals, and bacteria.

Hypothyroiddism has no effect on the primitive

18. A. The data suggests an infection of the

reflexes. Absence of the Moror reflex is the most

endometrial lining of the uterus. The lochia may

significant single indicator of central nervous

be decreased or copious, dark brown in

system status, but it is not a sign of increased

appearance, and foul smelling, providing further

intracranial pressure.

evidence of a possible infection. All the client’s

22. B. Hemorrhage is a potential risk following any

data indicate a uterine problem, not a breast

surgical procedure. Although the infant has been

problem. Typically, transient fever, usually 101ºF,

given vitamin K to facilitate clotting, the

may be present with breast engorgement.

prophylactic dose is often not sufficient to prevent

Symptoms of mastitis include influenza-like

bleeding. Although infection is a possibility, signs

manifestations. Localized infection of an

will not appear within 4 hours after the surgical

episiotomy or C-section incision rarely causes

procedure. The primary discomfort of circumcision

systemic symptoms, and uterine involution would

occurs during the surgical procedure, not

not be affected. The client data do not include

afterward. Although feedings are withheld prior to

dysuria, frequency, or urgency, symptoms of

the circumcision, the chances of dehydration are

urinary tract infections, which would necessitate

minimal.

assessing the client’s urine.

19. C. Because of early postpartum discharge and

23. B. The presence of excessive estrogen and progesterone in the maternal-fetal blood followed

limited time for teaching, the nurse’s priority is to

by prompt withdrawal at birth precipitates breast

facilitate the safe and effective care of the client

engorgement, which will spontaneously resolve in

and newborn. Although promoting comfort and

4 to 5 days after birth. The trauma of the birth

restoration of health, exploring the family’s

process does not cause inflammation of the

emotional status, and teaching about family

newborn’s breast tissue. Newborns do not have

planning are important in postpartum/newborn

breast malignancy. This reply by the nurse would

nursing care, they are not the priority focus in the

cause the mother to have undue anxiety. Breast

limited time presented by early post-partum

tissue does not hypertrophy in the fetus or

discharge.

newborns.

20. C. Heat loss by radiation occurs when the infant’s

24. D. The first 15 minutes to 1 hour after birth is the

crib is placed too near cold walls or windows. Thus

first period of reactivity involving respiratory and

placing the newborn’s crib close to the viewing

circulatory adaptation to extrauterine life. The

window would be least effective. Body heat is lost

data given reflect the normal changes during this

through evaporation during bathing. Placing the

time period. The infant’s assessment data reflect

infant under the radiant warmer after bathing will

normal adaptation. Thus, the physician does not

assist the infant to be rewarmed. Covering the

need to be notified and oxygen is not needed. The

scale with a warmed blanket prior to weighing

data do not indicate the presence of choking,

prevents heat loss through conduction. A knit cap

gagging or coughing, which are signs of excessive

prevents heat loss from the head a large head, a

secretions. Suctioning is not necessary.

large body surface area of the newborn’s body.

21. B. A fractured clavicle would prevent the normal

25. B. Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and

Moro response of symmetrical sequential

promotes drying. The cord should be kept dry until

extension and abduction of the arms followed by

it falls off and the stump has healed. Antibiotic

flexion and adduction. In talipes equinovarus

ointment should only be used to treat an infection,

(clubfoot) the foot is turned medially, and in

not as a prophylaxis. Infants should not be

plantar flexion, with the heel elevated. The feet

19 submerged in a tub of water until the cord falls off

inappropriate because this response does not

and the stump has completely healed.

provide the client with the specific information she

26. B. To determine the amount of formula needed, do

is requesting. Choice of a contraceptive method is

the following mathematical calculation. 3 kg x 120

important, but not the specific criteria for safe

cal/kg per day = 360 calories/day feeding q 4

resumption of sexual activity. Culturally, the 6-

hours = 6 feedings per day = 60 calories per

weeks’ examination has been used as the time

feeding: 60 calories per feeding; 60 calories per

frame for resuming sexual activity, but it may be

feeding with formula 20 cal/oz = 3 ounces per

resumed earlier.

feeding. Based on the calculation. 2, 4 or 6 ounces are incorrect.

27. A.

Intrauterine anoxia may cause relaxation of

31. C. The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels

the anal sphincter and emptying of meconium into

and nerves and is large enough to absorb the

the amniotic fluid. At birth some of the meconium

medication. The deltoid muscle of a newborn is

fluid may be aspirated, causing mechanical

not large enough for a newborn IM injection.

obstruction or chemical pneumonitis. The infant is

Injections into this muscle in a small child might

not at increased risk for gastrointestinal problems.

cause damage to the radial nerve. The anterior

Even though the skin is stained with meconium, it

femoris muscle is the next safest muscle to use in

is noninfectious (sterile) and nonirritating. The

a newborn but is not the safest. Because of the

postterm meconium-stained infant is not at

proximity of the sciatic nerve, the gluteus

additional risk for bowel or urinary problems.

maximus muscle should not be until the child has

28. C.

The nurse should use a nonelastic, flexible,

paper measuring tape, placing the zero point on

been walking 2 years.

32. D. Bartholin’s glands are the glands on either side

the superior border of the symphysis pubis and

of the vaginal orifice. The clitoris is female erectile

stretching the tape across the abdomen at the

tissue found in the perineal area above the

midline to the top of the fundus. The xiphoid and

urethra. The parotid glands are open into the

umbilicus are not appropriate landmarks to use

mouth. Skene’s glands open into the posterior wall

when measuring the height of the fundus

of the female urinary meatus.

(McDonald’s measurement).

29. B. Women hospitalized with severe preeclampsia

33. D. The fetal gonad must secrete estrogen for the embryo to differentiate as a female. An increase in

need decreased CNS stimulation to prevent a

maternal estrogen secretion does not effect

seizure. Seizure precautions provide

differentiation of the embryo, and maternal

environmental safety should a seizure occur.

estrogen secretion occurs in every pregnancy.

Because of edema, daily weight is important but

Maternal androgen secretion remains the same as

not the priority. Preclampsia causes vasospasm

before pregnancy and does not effect

and therefore can reduce utero-placental

differentiation. Secretion of androgen by the fetal

perfusion. The client should be placed on her left

gonad would produce a male fetus.

side to maximize blood flow, reduce blood

34. A. Using bicarbonate would increase the amount

pressure, and promote diuresis. Interventions to

of sodium ingested, which can cause

reduce stress and anxiety are very important to

complications. Eating low-sodium crackers would

facilitate coping and a sense of control, but

be appropriate. Since liquids can increase nausea

seizure precautions are the priority.

avoiding them in the morning hours when nausea

30. C. Cessation of the lochial discharge signifies

is usually the strongest is appropriate. Eating six

healing of the endometrium. Risk of hemorrhage

small meals a day would keep the stomach full,

and infection are minimal 3 weeks after a normal

which often decrease nausea.

vaginal delivery. Telling the client anytime is

20 35. B. Ballottement indicates passive movement of

not explain why the hemorrhage could occur. With

the unengaged fetus. Ballottement is not a

a complete previa, the placenta is covering all the

contraction. Fetal kicking felt by the client

cervix, not just most of it.

represents quickening. Enlargement and softening of the uterus is known as Piskacek’s sign.

41. B. With a face presentation, the head is completely extended. With a vertex presentation,

36. B. Chadwick’s sign refers to the purple-blue tinge

the head is completely or partially flexed. With a

of the cervix. Braxton Hicks contractions are

brow (forehead) presentation, the head would be

painless contractions beginning around the

partially extended.

4th month. Goodell’s sign indicates softening of the

42. D. With this presentation, the fetal upper torso

cervix. Flexibility of the uterus against the cervix

and back face the left upper maternal abdominal

is known as McDonald’s sign.

wall. The fetal heart rate would be most audible

37. C. Breathing techniques can raise the pain threshold and reduce the perception of pain. They also promote relaxation. Breathing techniques do

above the maternal umbilicus and to the left of the middle. The other positions would be incorrect.

43. C. The greenish tint is due to the presence of

not eliminate pain, but they can reduce it.

meconium. Lanugo is the soft, downy hair on the

Positioning, not breathing, increases

shoulders and back of the fetus. Hydramnios

uteroplacental perfusion.

represents excessive amniotic fluid. Vernix is the

38. A. The client’s labor is hypotonic. The nurse should call the physical and obtain an order for an

white, cheesy substance covering the fetus.

44. D. In a breech position, because of the space

infusion of oxytocin, which will assist the uterus to

between the presenting part and the cervix,

contact more forcefully in an attempt to dilate the

prolapse of the umbilical cord is common.

cervix. Administering light sedative would be done

Quickening is the woman’s first perception of fetal

for hypertonic uterine contractions. Preparing for

movement. Ophthalmia neonatorum usually

cesarean section is unnecessary at this time.

results from maternal gonorrhea and is

Oxytocin would increase the uterine contractions

conjunctivitis. Pica refers to the oral intake of

and hopefully progress labor before a cesarean

nonfood substances.

would be necessary. It is too early to anticipate client pushing with contractions.

39. D. The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage.

45. A. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. Monozygotic (identical) twins involve a common placenta, same genotype, and common chorion.

46. C. The zygote is the single cell that reproduces

Assessing maternal vital signs can help determine

itself after conception. The chromosome is the

maternal physiologic status. Fetal heart rate is

material that makes up the cell and is gained from

important to assess fetal well-being and should be

each parent. Blastocyst and trophoblast are later

done. Monitoring the contractions will help

terms for the embryo after zygote.

evaluate the progress of labor.

47. D. Prepared childbirth was the direct result of the

40. D. A complete placenta previa occurs when the

1950’s challenging of the routine use of analgesic

placenta covers the opening of the uterus, thus

and anesthetics during childbirth. The LDRP was a

blocking the passageway for the baby. This

much later concept and was not a direct result of

response explains what a complete previa is and

the challenging of routine use of analgesics and

the reason the baby cannot come out except by

anesthetics during childbirth. Roles for nurse

cesarean delivery. Telling the client to ask the

midwives and clinical nurse specialists did not

physician is a poor response and would increase

develop from this challenge.

the patient’s anxiety. Although a cesarean would

48. C. The ischial spines are located in the mid-pelvic

help to prevent hemorrhage, the statement does

region and could be narrowed due to the previous

21 pelvic injury. The symphysis pubis, sacral promontory, and pubic arch are not part of the mid-pelvis.

49. B. Variations in the length of the menstrual cycle are due to variations in the proliferative phase. The menstrual, secretory and ischemic phases do not contribute to this variation.

50. B. Testosterone is produced by the Leyding cells in the seminiferous tubules. Follicle-stimulating hormone and leuteinzing hormone are released by the anterior pituitary gland. The hypothalamus is responsible for releasing gonadotropin-releasing hormone.